Displaying publications 1 - 20 of 208 in total

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  1. Mohd Isa, S., Hashim, A.H., Kaur, M., Ng, C.G.
    MyJurnal
    Objective: As Internet use becomes ubiquitous among adolescents, Internet
    addiction turns out to be as a potential problem in adolescents. The aim of
    this cross-sectional study was to examine the prevalence of internet addiction
    and its associated factors among the adolescents in Malaysia.

    Methods: The
    association between internet addiction and attention deficit hyperactivity
    disorder (ADHD) symptoms was also examined in this cross-sectional study,
    which was conducted at four secondary schools in Malaysia. In this study,
    Malaysian Version of Internet Addiction Test (MVIAT), Conners-Wells
    Adolescent Self-report: Short Form (CASS:S), The Conners Teachers Rating
    Scale: Short Form (CTRS:S) and The Conners’ Parents Rating Scale: Short
    For (CPRS: S) were used.

    Results: The results demonstrated 28.6% of the
    subjects were addicted to the internet and there was a positive association
    with ADHD symptoms. Male gender, early age of first internet use, longer
    total time of internet use are associated with internet addiction problem
    among the adolescents. Internet addiction has become highly prevalent
    among the adolescent in Malaysia.

    Conclusions: It is important to provide
    support for this group of adolescent with internet use problem. Measure to
    prevent the worsening of the situation and future research on the causal
    factors of internet addiction such as ADHD is needed.
  2. Md. Muziman Syah, M.M., Mutalib, H. A., Sharanjeet Kaur, M. S., Khairidzan, M. K.
    MyJurnal
    Introduction: The purpose of this study was to derive a modified equation for contact lens method (CLM) in
    calculating post myopic laser refractive surgery corneal power. Methods: A total of 93 subjects who
    underwent myopic laser refractive surgery at IIUM Eye Specialist Clinic were recruited. The accuracy of
    postoperative corneal power using the standard CLM and newly-derived contact lens modified method
    (CLMmod) were compared to the standard comparison method ; the historical method (HM). The CLMmod
    equation was derived by adjusting postoperative corneal power of CLM according to amount of refractive
    change. Results: The mean postoperative corneal power using standard CLM was significantly higher than
    HM (mean difference: -0.24 D, p < 0.001). Fifty seven percent (n = 53 eyes) of the standard CLM results were
    within ±0.50 D of HM results. The difference between postoperative corneal power using standard CLM and
    HM increased significantly with the amount of refractive change (r = 0.835; p < 0.001). The mean
    postoperative corneal power of CLMmod showed that there was no statistical significant difference compared
    to the HM results (mean difference: 0.00 D, p= 0.964). Eighty eight percent (n = 82 eyes) of the CLMmod
    results were within ±0.50 D of HM results with improvement of 31% from the standard CLM results.
    Conclusion: The CLMmod equation provides more accurate calculation in determining post myopic laser
    refractive surgery corneal power. In near future, this modified equation can be used as an alternative
    equation to calculate postoperative corneal power when the preoperative data is unavailable.
  3. Md. Muziman Syah, M. M., Mutalib, H. A., Sharanjeet Kaur, M. S., Khairidzan Khairidzan, M. K.
    MyJurnal
    Introduction: The purpose of this study was to evaluate inter-session repeatability, inter-examiner
    reproducibility and inter-device agreement of corneal power measurements from manual keratometer,
    autokeratometer, topographer, Pentacam high resolution and IOLMaster. Methods: Two sets of mean
    corneal power measurements (n=40) were compared for inter-session repeatability and inter-examiner
    reproducibility in each instrument. Repeatability and reproducibility were evaluated by within-subject
    standard deviation (Sw), coefficient of variation (COV) and intraclass correlation coefficient (ICC). A oneway
    repeated measures analysis of variance was conducted to compare differences in the corneal power
    between each instrument pair. The Bland and Altman analysis and Pearson’s correlation were employed to
    assess agreement and determine strength of relationship between measurements. Results: There were no
    significant differences in mean corneal power measurements between 2 different visits (p > 0.05). The Sw
    and COV values between 2 visits were lower than 0.09 D and 0.20 % respectively. The ICCs were stronger
    than 0.99 in all instruments. For reproducibility of each instrument, differences of the measurements
    between 2 different examiners were also insignificant (p > 0.05). The Sw and COV values between 2
    examiners were lower than 0.11 D and 0.23 % respectively. The ICCs were 0.99 and above in all instruments.
    The 95% limit of agreement between instruments ranged from -0.29 to 1.13 D and the r-values were stronger
    than 0.84. Conclusion: The corneal power measurements using these 5 instruments were repeatable and
    reproducible. These instruments can also be used interchangeably, however the topographer should be used
    with caution.
  4. Isa MR, Mohd Noor N, Nawawi H, Kaur M., Rahman T, Mohd Kornain NK, et al.
    MyJurnal
    Imaging techniques involving optical coherence tomography, computed tomography (CT) and high-resolution magnetic resonance imaging (MRI) are used as tools to identify atherosclerotic plaques. However, the effects of water-based contrast media used in Post Mortem Computed Tomography Angiography (PMCTA) on the histopathology of atherosclerotic plaques have not been widely explored. The objective of this study is to determine the effects of water-based contrast media used in PMCTA on the histopathology of atherosclerotic plaques and biomarkers of atherosclerosis in experimentally induced established atherosclerotic rabbits. MATERIALS AND METHODS: Twenty male New Zealand white rabbits were divided into 2 groups. One group was given a high cholesterol diet (HCD) for 12 weeks to establish atherosclerosis and the control group normal diet (ND). Five rabbits from each group were then given intravenous water-based contrast media before being sacrificed. The entire length of aorta was dissected and submitted for histopathological examination and determination of tissue biomarkers α-SMA and MMP-9. RESULTS:Histopathological examination of the aorta including percentage of area covered by plaque and foam cell formation showed no significant difference in atheromatous plaque formation in both groups of HCD rabbits with or without intravenous contrast media injection (plaque: 55±41 vs. 63±15, p=0.731; foam cells: 124±83 vs. 171±55, p=0.325). Similarly, α-SMA and MMP-9 protein expression also showed no significant difference in both groups (α-SMA: 70±20 vs. 67±26, p=0.807; MMP-9: 60±12 vs. 57±17, p=0.785). CONCLUSION:Water-based contrast media used in PMCTA does not affect the morphology or the immunohistochemistry staining of SMA and MMP-9 in atherosclerotic plaques.
  5. Kaur M, Verma S, Gupta R, Pant L, Singh S
    Malays J Pathol, 2018 Apr;40(1):57-60.
    PMID: 29704385
    CD10, a transmembrane endopeptidase, has been shown to be lost as an early event in prostate cancer. We aimed at evaluating the pattern of expression of CD10 in various Gleason's grades of prostatic adenocarcinoma in comparison with nodular hyperplasia of prostate. This retrospective study included 30 cases of nodular hyperplasia and 30 of prostatic adenocarcinoma of various Gleason's grades. Immunohistochemical staining for CD10 was performed on all cases and positivity evaluated as percentage of cells as well as location (membranous or cytoplasmic or both). Of prostatic adenocarcinomas, grade 3 was seen in 10 foci, grade 4 in 28 and grade 5 in 22 foci. CD10 positivity in carcinoma was lower than in nodular hyperplasia, with the lowest positivity in grade 5. The pattern of expression of CD10 also changed from membranous in grade 3 to cytoplasmic in grade 5. Loss of CD10 expression appears to be associated with increasing tumour grade in carcinoma prostate and this can potentially be useful in stratification of such patients.
  6. Sathiaray D, Kaur M, Hanim A, Ng CG, Siau CS
    PMID: 34706594 DOI: 10.1177/10105395211053730
    This study aimed to identify the prevalence of psychological distress and its association with sociodemographic characteristics, burden of care, and the coping strategies used by childminders in residential homes. A total of 151 childminders (median age = 39; 64.7% female) participated in the study. The prevalence of psychological distress was 59.4%, and 74.0% recorded mild to moderate burden. Multivariate analyses showed that caregiver burden (adjusted beta = 0.464, P = .01), lesser application of problem-focused coping (adjusted beta = -0.292, P = .012), lower salary (adjusted beta = -0.196, P = .040), and lower educational qualification (adjusted beta = -0.212, P = .038) predicted higher psychological distress. Regular screening of psychological distress and burden of care is recommended among this population.
  7. Kaur M, Rahimi R, Razali F, Mohd Noor N, Omar E, Abdul Manaf Z, et al.
    Malays J Pathol, 2019 Aug;41(2):177-183.
    PMID: 31427553
    INTRODUCTION: Coronary artery disease (CAD) is a known cause of major cardiovascular events and calcium score (CS) has been developed as a marker of coronary atherosclerosis. Yet, the relationship between post mortem computed tomography (PMCT) CS with histologically observed calcification and the severity of coronary artery stenosis has not been widely explored and is still unclear. This study aims to determine the association between coronary artery PMCT CS with histologically observed calcification and degree of stenosis of coronary arteries in post-mortem cases.

    MATERIALS & METHODS: This was a cross-sectional study involving 101 subjects recruited from the National Institute of Forensic Medicine (IPFN) Hospital Kuala Lumpur (HKL) over a period of 15 months, from December 2012 until April 2014. PMCT CS of the coronary arteries was calculated using Agatston-Janowitz score. Histological presence of calcification was observed and the degree of stenosis was calculated using an image analysis technique.

    RESULTS: PMCT CS increased with increasing severity of stenosis (p<0.001). PMCT CS showed a positive correlation with the presence of calcification (r=-0.82, p<0.001).

    CONCLUSION: Calcium score is strongly associated with coronary artery calcification and the degree of luminal stenosis in post mortem subjects. Thus, PMCT may be useful as a non-invasive tool in diagnosing CAD in the event that an autopsy is not possible.

  8. Lee MHL, Kaur M, Shaker V, Yee A, Sham R, Siau CS
    PMID: 36833827 DOI: 10.3390/ijerph20043136
    This study aims to determine the prevalence and factors associated with cyberbullying and social media addiction. This cross-sectional study was conducted among 270 medical students from a public university in Kuching, Malaysia. The instruments used in this study included the cyberbullying questionnaire survey, Bergen Social Media Addiction Scale (BSMAS), and the Depression Anxiety Stress Scale 21-item (DASS-21). The prevalence of cyberbullying victimization was 24.4%, whilst 13.0% reported cyberbullying perpetration over the past six months. Male gender was positively associated with both cyberbullying perpetration and cybervictimization, whilst social media addiction was positively associated with cybervictimization. Psychological motives such as positive attitudes toward cyberbullying and gaining power were associated with cyberbullying perpetration. Cybervictimization doubled the tendency to depression (aOR 2.50, 95% CI [1.23, 5.08], p = 0.012), anxiety (aOR 2.38, 95% CI [1.29, 4.40], p = 0.006), and stress (aOR 2.85, 95% CI [1.41, 5.77], p = 0.004), whilst social media addiction was associated with a higher tendency to depression (aOR 1.18, 95% CI [1.10, 1.26], p < 0.001), anxiety (aOR 1.15, 95% CI [1.08, 1.22], p < 0.001), and stress (aOR 1.21, 95% CI [1.12, 1.32], p < 0.001). Medical schools in Malaysia need policies and guidelines against cyberbullying.
  9. Menon S, Anand D, Kavita, Verma S, Kaur M, Jhanjhi NZ, et al.
    Sensors (Basel), 2023 Jul 04;23(13).
    PMID: 37447981 DOI: 10.3390/s23136132
    With the increasing growth rate of smart home devices and their interconnectivity via the Internet of Things (IoT), security threats to the communication network have become a concern. This paper proposes a learning engine for a smart home communication network that utilizes blockchain-based secure communication and a cloud-based data evaluation layer to segregate and rank data on the basis of three broad categories of Transactions (T), namely Smart T, Mod T, and Avoid T. The learning engine utilizes a neural network for the training and classification of the categories that helps the blockchain layer with improvisation in the decision-making process. The contributions of this paper include the application of a secure blockchain layer for user authentication and the generation of a ledger for the communication network; the utilization of the cloud-based data evaluation layer; the enhancement of an SI-based algorithm for training; and the utilization of a neural engine for the precise training and classification of categories. The proposed algorithm outperformed the Fused Real-Time Sequential Deep Extreme Learning Machine (RTS-DELM) system, the data fusion technique, and artificial intelligence Internet of Things technology in providing electronic information engineering and analyzing optimization schemes in terms of the computation complexity, false authentication rate, and qualitative parameters with a lower average computation complexity; in addition, it ensures a secure, efficient smart home communication network to enhance the lifestyle of human beings.
  10. Kaur K, Sulaiman AH, Yoon CK, Hashim AH, Kaur M, Hui KO, et al.
    PMID: 32942770 DOI: 10.3390/ijerph17186730
    Mental health disorders (MHDs) among refugees has been recognized as a major public health issue. However, to date, there is limited evidence on the prevalence of MHDs among Rohingya refugees in Malaysia. This study aimed to examine the prevalence and associated factors of major depressive disorder (MDD), generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD) among Rohingya refugees in Malaysia. A total of 220 refugees were randomly selected to participate in this cross-sectional study, conducted from June 2019 to November 2019. Perceived social support, religious orientation, food security, and sociodemographic characteristics were assessed as independent variables. The dependent variables assessed were MDD, GAD, and PTSD. The prevalence of GAD, PTSD, and MDD was reported at 92 (41.8%), 84 (38.2%), and 71 (32.3%). Several factors were significantly associated with MDD following multivariate analysis such as perceived low to moderate social support (AOR = 2.17; 95% CI 1.13, 4.19) and food insecurity (AOR = 2.77; 95% CI 1.19, 6.47). Exposure to violence (AOR = 38.46; 95% CI 16.27, 90.91) and food insecurity (AOR = 3.74; 95% CI 1.41, 9.91) were significantly associated with PTSD. Addressing these risk factors could be key in improving mental health outcomes among this vulnerable population.
  11. Kaur P, Sandhu KS, Bangar SP, Purewal SS, Kaur M, Ilyas RA, et al.
    Antioxidants (Basel), 2021 Jul 28;10(8).
    PMID: 34439463 DOI: 10.3390/antiox10081214
    Six different solvents were used as extraction medium (water, methanol, ethanol, acidified methanol, benzene and acetone) to check their phenolics extraction efficacy from flour of two rye cultivars. Rye extracts with different solvents were further analyzed for the estimation of phytochemicals and antioxidant properties. Different tests (TPC, TAC, DPPH, FRAP, ABTS, RPA and CTC) were performed to check the antioxidant properties and tannin contents in extracts. A bioactive profile of a rye cultivar indicated the presence of total phenolic compounds (0.08-2.62 mg GAE/g), total antioxidant capacity (0.9-6.8 mg AAE/g) and condensed tannin content (4.24-9.28 mg CE/100 g). HPLC was done to check phenolics in rye extract with the best solvent (water), which indicated the presence of Catechol (91.1-120.4 mg/100 g), resorcinol (52-70.3 mg/100 g), vanillin (1.3-5.5 mg/100 g), ferulic acid (1.4-1.5 mg/100 g), quercetin (4.6-4.67 mg/100 g) and benzoic acid (5.3 mg/100 g) in rye extracts. The presence of DNA damage protection potential in rye extracts indicates its medicinal importance. Rye flour could be utilized in the preparation of antioxidant-rich health-benefiting food products.
  12. Kour D, Khan SS, Kumari S, Singh S, Khan RT, Kumari C, et al.
    PMID: 38421484 DOI: 10.1007/s12223-024-01147-2
    The field of nanotechnology has the mysterious capacity to reform every subject it touches. Nanotechnology advancements have already altered a variety of scientific and industrial fields. Nanoparticles (NPs) with sizes ranging from 1 to 100 nm (nm) are of great scientific and commercial interest. Their functions and characteristics differ significantly from those of bulk metal. Commercial quantities of NPs are synthesized using chemical or physical methods. The use of the physical and chemical approaches remained popular for many years; however, the recognition of their hazardous effects on human well-being and conditions influenced serious world perspectives for the researchers. There is a growing need in this field for simple, non-toxic, clean, and environmentally safe nanoparticle production methods to reduce environmental impact and waste and increase energy productivity. Microbial nanotechnology is relatively a new field. Using various microorganisms, a wide range of nanoparticles with well-defined chemical composition, morphology, and size have been synthesized, and their applications in a wide range of cutting-edge technological areas have been investigated. Green synthesis of the nanoparticles is cost-efficient and requires low maintenance. The present review highlights the synthesis of the nanoparticles by different microbes, their characterization, and their biotechnological potential. It further deals with the applications in biomedical, food, and textile industries as well as its role in biosensing, waste recycling, and biofuel production.
  13. Dagenais GR, Leong DP, Rangarajan S, Lanas F, Lopez-Jaramillo P, Gupta R, et al.
    Lancet, 2020 03 07;395(10226):785-794.
    PMID: 31492501 DOI: 10.1016/S0140-6736(19)32007-0
    BACKGROUND: To our knowledge, no previous study has prospectively documented the incidence of common diseases and related mortality in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) with standardised approaches. Such information is key to developing global and context-specific health strategies. In our analysis of the Prospective Urban Rural Epidemiology (PURE) study, we aimed to evaluate differences in the incidence of common diseases, related hospital admissions, and related mortality in a large contemporary cohort of adults from 21 HICs, MICs, and LICs across five continents by use of standardised approaches.

    METHODS: The PURE study is a prospective, population-based cohort study of individuals aged 35-70 years who have been enrolled from 21 countries across five continents. The key outcomes were the incidence of fatal and non-fatal cardiovascular diseases, cancers, injuries, respiratory diseases, and hospital admissions, and we calculated the age-standardised and sex-standardised incidence of these events per 1000 person-years.

    FINDINGS: This analysis assesses the incidence of events in 162 534 participants who were enrolled in the first two phases of the PURE core study, between Jan 6, 2005, and Dec 4, 2016, and who were assessed for a median of 9·5 years (IQR 8·5-10·9). During follow-up, 11 307 (7·0%) participants died, 9329 (5·7%) participants had cardiovascular disease, 5151 (3·2%) participants had a cancer, 4386 (2·7%) participants had injuries requiring hospital admission, 2911 (1·8%) participants had pneumonia, and 1830 (1·1%) participants had chronic obstructive pulmonary disease (COPD). Cardiovascular disease occurred more often in LICs (7·1 cases per 1000 person-years) and in MICs (6·8 cases per 1000 person-years) than in HICs (4·3 cases per 1000 person-years). However, incident cancers, injuries, COPD, and pneumonia were most common in HICs and least common in LICs. Overall mortality rates in LICs (13·3 deaths per 1000 person-years) were double those in MICs (6·9 deaths per 1000 person-years) and four times higher than in HICs (3·4 deaths per 1000 person-years). This pattern of the highest mortality in LICs and the lowest in HICs was observed for all causes of death except cancer, where mortality was similar across country income levels. Cardiovascular disease was the most common cause of deaths overall (40%) but accounted for only 23% of deaths in HICs (vs 41% in MICs and 43% in LICs), despite more cardiovascular disease risk factors (as judged by INTERHEART risk scores) in HICs and the fewest such risk factors in LICs. The ratio of deaths from cardiovascular disease to those from cancer was 0·4 in HICs, 1·3 in MICs, and 3·0 in LICs, and four upper-MICs (Argentina, Chile, Turkey, and Poland) showed ratios similar to the HICs. Rates of first hospital admission and cardiovascular disease medication use were lowest in LICs and highest in HICs.

    INTERPRETATION: Among adults aged 35-70 years, cardiovascular disease is the major cause of mortality globally. However, in HICs and some upper-MICs, deaths from cancer are now more common than those from cardiovascular disease, indicating a transition in the predominant causes of deaths in middle-age. As cardiovascular disease decreases in many countries, mortality from cancer will probably become the leading cause of death. The high mortality in poorer countries is not related to risk factors, but it might be related to poorer access to health care.

    FUNDING: Full funding sources are listed at the end of the paper (see Acknowledgments).

  14. Naito R, Leong DP, Bangdiwala SI, McKee M, Subramanian SV, Rangarajan S, et al.
    BMJ Glob Health, 2021 03;6(3).
    PMID: 33753400 DOI: 10.1136/bmjgh-2020-004124
    OBJECTIVE: To examine the association between social isolation and mortality and incident diseases in middle-aged adults in urban and rural communities from high-income, middle-income and low-income countries.

    DESIGN: Population-based prospective observational study.

    SETTING: Urban and rural communities in 20 high income, middle income and low income.

    PARTICIPANTS: 119 894 community-dwelling middle-aged adults.

    MAIN OUTCOME MEASURES: Associations of social isolation with mortality, cardiovascular death, non-cardiovascular death and incident diseases.

    RESULTS: Social isolation was more common in middle-income and high-income countries compared with low-income countries, in urban areas than rural areas, in older individuals and among women, those with less education and the unemployed. It was more frequent among smokers and those with a poorer diet. Social isolation was associated with greater risk of mortality (HR of 1.26, 95% CI: 1.17 to 1.36), incident stroke (HR: 1.23, 95% CI: 1.07 to 1.40), cardiovascular disease (HR: 1.15, 95% CI: 1.05 to 1.25) and pneumonia (HR: 1.22, 95% CI: 1.09 to 1.37), but not cancer. The associations between social isolation and mortality were observed in populations in high-income, middle-income and low-income countries (HR (95% CI): 1.69 (1.32 to 2.17), 1.27 (1.15 to 1.40) and 1.47 (1.25 to 1.73), respectively, interaction p=0.02). The HR associated with social isolation was greater in men than women and in younger than older individuals. Mediation analyses for the association between social isolation and mortality showed that unhealthy behaviours and comorbidities may account for about one-fifth of the association.

    CONCLUSION: Social isolation is associated with increased risk of mortality in countries at different economic levels. The increasing share of older people in populations in many countries argues for targeted strategies to mitigate its adverse effects.

  15. Walli-Attaei M, Joseph P, Rosengren A, Chow CK, Rangarajan S, Lear SA, et al.
    Lancet, 2020 07 11;396(10244):97-109.
    PMID: 32445693 DOI: 10.1016/S0140-6736(20)30543-2
    BACKGROUND: Some studies, mainly from high-income countries (HICs), report that women receive less care (investigations and treatments) for cardiovascular disease than do men and might have a higher risk of death. However, very few studies systematically report risk factors, use of primary or secondary prevention medications, incidence of cardiovascular disease, or death in populations drawn from the community. Given that most cardiovascular disease occurs in low-income and middle-income countries (LMICs), there is a need for comprehensive information comparing treatments and outcomes between women and men in HICs, middle-income countries, and low-income countries from community-based population studies.

    METHODS: In the Prospective Urban Rural Epidemiological study (PURE), individuals aged 35-70 years from urban and rural communities in 27 countries were considered for inclusion. We recorded information on participants' sociodemographic characteristics, risk factors, medication use, cardiac investigations, and interventions. 168 490 participants who enrolled in the first two of the three phases of PURE were followed up prospectively for incident cardiovascular disease and death.

    FINDINGS: From Jan 6, 2005 to May 6, 2019, 202 072 individuals were recruited to the study. The mean age of women included in the study was 50·8 (SD 9·9) years compared with 51·7 (10) years for men. Participants were followed up for a median of 9·5 (IQR 8·5-10·9) years. Women had a lower cardiovascular disease risk factor burden using two different risk scores (INTERHEART and Framingham). Primary prevention strategies, such as adoption of several healthy lifestyle behaviours and use of proven medicines, were more frequent in women than men. Incidence of cardiovascular disease (4·1 [95% CI 4·0-4·2] for women vs 6·4 [6·2-6·6] for men per 1000 person-years; adjusted hazard ratio [aHR] 0·75 [95% CI 0·72-0·79]) and all-cause death (4·5 [95% CI 4·4-4·7] for women vs 7·4 [7·2-7·7] for men per 1000 person-years; aHR 0·62 [95% CI 0·60-0·65]) were also lower in women. By contrast, secondary prevention treatments, cardiac investigations, and coronary revascularisation were less frequent in women than men with coronary artery disease in all groups of countries. Despite this, women had lower risk of recurrent cardiovascular disease events (20·0 [95% CI 18·2-21·7] versus 27·7 [95% CI 25·6-29·8] per 1000 person-years in men, adjusted hazard ratio 0·73 [95% CI 0·64-0·83]) and women had lower 30-day mortality after a new cardiovascular disease event compared with men (22% in women versus 28% in men; p<0·0001). Differences between women and men in treatments and outcomes were more marked in LMICs with little differences in HICs in those with or without previous cardiovascular disease.

    INTERPRETATION: Treatments for cardiovascular disease are more common in women than men in primary prevention, but the reverse is seen in secondary prevention. However, consistently better outcomes are observed in women than in men, both in those with and without previous cardiovascular disease. Improving cardiovascular disease prevention and treatment, especially in LMICs, should be vigorously pursued in both women and men.

    FUNDING: Full funding sources are listed at the end of the paper (see Acknowledgments).

  16. Tse LA, Wang C, Rangarajan S, Liu Z, Teo K, Yusufali A, et al.
    JAMA Netw Open, 2021 06 01;4(6):e2113775.
    PMID: 34190997 DOI: 10.1001/jamanetworkopen.2021.13775
    Importance: Obesity is a growing public health threat leading to serious health consequences. Late bedtime and sleep loss are common in modern society, but their associations with specific obesity types are not well characterized.

    Objective: To assess whether sleep timing and napping behavior are associated with increased obesity, independent of nocturnal sleep length.

    Design, Setting, and Participants: This large, multinational, population-based cross-sectional study used data of participants from 60 study centers in 26 countries with varying income levels as part of the Prospective Urban Rural Epidemiology study. Participants were aged 35 to 70 years and were mainly recruited during 2005 and 2009. Data analysis occurred from October 2020 through March 2021.

    Exposures: Sleep timing (ie, bedtime and wake-up time), nocturnal sleep duration, daytime napping.

    Main Outcomes and Measures: The primary outcomes were prevalence of obesity, specified as general obesity, defined as body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 30 or greater, and abdominal obesity, defined as waist circumference greater than 102 cm for men or greater than 88 cm for women. Multilevel logistic regression models with random effects for study centers were performed to calculate adjusted odds ratios (AORs) and 95% CIs.

    Results: Overall, 136 652 participants (81 652 [59.8%] women; mean [SD] age, 51.0 [9.8] years) were included in analysis. A total of 27 195 participants (19.9%) had general obesity, and 37 024 participants (27.1%) had abdominal obesity. The mean (SD) nocturnal sleep duration was 7.8 (1.4) hours, and the median (interquartile range) midsleep time was 2:15 am (1:30 am-3:00 am). A total of 19 660 participants (14.4%) had late bedtime behavior (ie, midnight or later). Compared with bedtime between 8 pm and 10 pm, late bedtime was associated with general obesity (AOR, 1.20; 95% CI, 1.12-1.29) and abdominal obesity (AOR, 1.20; 95% CI, 1.12-1.28), particularly among participants who went to bed between 2 am and 6 am (general obesity: AOR, 1.35; 95% CI, 1.18-1.54; abdominal obesity: AOR, 1.38; 95% CI, 1.21-1.58). Short nocturnal sleep of less than 6 hours was associated with general obesity (eg, <5 hours: AOR, 1.27; 95% CI, 1.13-1.43), but longer napping was associated with higher abdominal obesity prevalence (eg, ≥1 hours: AOR, 1.39; 95% CI, 1.31-1.47). Neither going to bed during the day (ie, before 8pm) nor wake-up time was associated with obesity.

    Conclusions and Relevance: This cross-sectional study found that late nocturnal bedtime and short nocturnal sleep were associated with increased risk of obesity prevalence, while longer daytime napping did not reduce the risk but was associated with higher risk of abdominal obesity. Strategic weight control programs should also encourage earlier bedtime and avoid short nocturnal sleep to mitigate obesity epidemic.

  17. Santosa A, Rosengren A, Ramasundarahettige C, Rangarajan S, Chifamba J, Lear SA, et al.
    JAMA Netw Open, 2021 12 01;4(12):e2138920.
    PMID: 34910150 DOI: 10.1001/jamanetworkopen.2021.38920
    Importance: Stress may increase the risk of cardiovascular disease (CVD). Most studies on stress and CVD have been conducted in high-income Western countries, but whether stress is associated with CVD in other settings has been less well studied.

    Objective: To investigate the association of a composite measure of psychosocial stress and the development of CVD events and mortality in a large prospective study involving populations from 21 high-, middle-, and low-income countries across 5 continents.

    Design, Setting, and Participants: This population-based cohort study used data from the Prospective Urban Rural Epidemiology study, collected between January 2003 and March 2021. Participants included individuals aged 35 to 70 years living in 21 low-, middle-, and high-income countries. Data were analyzed from April 8 to June 15, 2021.

    Exposures: All participants were assessed on a composite measure of psychosocial stress assessed at study entry using brief questionnaires concerning stress at work and home, major life events, and financial stress.

    Main Outcomes and Measures: The outcomes of interest were stroke, major coronary heart disease (CHD), CVD, and all-cause mortality.

    Results: A total of 118 706 participants (mean [SD] age 50.4 [9.6] years; 69 842 [58.8%] women and 48 864 [41.2%] men) without prior CVD and with complete baseline and follow-up data were included. Of these, 8699 participants (7.3%) reported high stress, 21 797 participants (18.4%) reported moderate stress, 34 958 participants (29.4%) reported low stress, and 53 252 participants (44.8%) reported no stress. High stress, compared with no stress, was more likely with younger age (mean [SD] age, 48.9 [8.9] years vs 51.1 [9.8] years), abdominal obesity (2981 participants [34.3%] vs 10 599 participants [19.9%]), current smoking (2319 participants [26.7%] vs 10 477 participants [19.7%]) and former smoking (1571 participants [18.1%] vs 3978 participants [7.5%]), alcohol use (4222 participants [48.5%] vs 13 222 participants [24.8%]), and family history of CVD (5435 participants [62.5%] vs 20 255 participants [38.0%]). During a median (IQR) follow-up of 10.2 (8.6-11.9) years, a total of 7248 deaths occurred. During the course of follow-up, there were 5934 CVD events, 4107 CHD events, and 2880 stroke events. Compared with no stress and after adjustment for age, sex, education, marital status, location, abdominal obesity, hypertension, smoking, diabetes, and family history of CVD, as the level of stress increased, there were increases in risk of death (low stress: hazard ratio [HR], 1.09 [95% CI, 1.03-1.16]; high stress: 1.17 [95% CI, 1.06-1.29]) and CHD (low stress: HR, 1.09 [95% CI, 1.01-1.18]; high stress: HR, 1.24 [95% CI, 1.08-1.42]). High stress, but not low or moderate stress, was associated with CVD (HR, 1.22 [95% CI, 1.08-1.37]) and stroke (HR, 1.30 [95% CI, 1.09-1.56]) after adjustment.

    Conclusions and Relevance: This cohort study found that higher psychosocial stress, measured as a composite score of self-perceived stress, life events, and financial stress, was significantly associated with mortality as well as with CVD, CHD, and stroke events.

  18. Mohan D, Mente A, Dehghan M, Rangarajan S, O'Donnell M, Hu W, et al.
    JAMA Intern Med, 2021 05 01;181(5):631-649.
    PMID: 33683310 DOI: 10.1001/jamainternmed.2021.0036
    Importance: Cohort studies report inconsistent associations between fish consumption, a major source of long-chain ω-3 fatty acids, and risk of cardiovascular disease (CVD) and mortality. Whether the associations vary between those with and those without vascular disease is unknown.

    Objective: To examine whether the associations of fish consumption with risk of CVD or of mortality differ between individuals with and individuals without vascular disease.

    Design, Setting, and Participants: This pooled analysis of individual participant data involved 191 558 individuals from 4 cohort studies-147 645 individuals (139 827 without CVD and 7818 with CVD) from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study and 43 413 patients with vascular disease in 3 prospective studies from 40 countries. Adjusted hazard ratios (HRs) were calculated by multilevel Cox regression separately within each study and then pooled using random-effects meta-analysis. This analysis was conducted from January to June 2020.

    Exposures: Fish consumption was recorded using validated food frequency questionnaires. In 1 of the cohorts with vascular disease, a separate qualitative food frequency questionnaire was used to assess intake of individual types of fish.

    Main Outcomes and Measures: Mortality and major CVD events (including myocardial infarction, stroke, congestive heart failure, or sudden death).

    Results: Overall, 191 558 participants with a mean (SD) age of 54.1 (8.0) years (91 666 [47.9%] male) were included in the present analysis. During 9.1 years of follow-up in PURE, compared with little or no fish intake (≤50 g/mo), an intake of 350 g/wk or more was not associated with risk of major CVD (HR, 0.95; 95% CI, 0.86-1.04) or total mortality (HR, 0.96; 0.88-1.05). By contrast, in the 3 cohorts of patients with vascular disease, the HR for risk of major CVD (HR, 0.84; 95% CI, 0.73-0.96) and total mortality (HR, 0.82; 95% CI, 0.74-0.91) was lowest with intakes of at least 175 g/wk (or approximately 2 servings/wk) compared with 50 g/mo or lower, with no further apparent decrease in HR with consumption of 350 g/wk or higher. Fish with higher amounts of ω-3 fatty acids were strongly associated with a lower risk of CVD (HR, 0.94; 95% CI, 0.92-0.97 per 5-g increment of intake), whereas other fish were neutral (collected in 1 cohort of patients with vascular disease). The association between fish intake and each outcome varied by CVD status, with a lower risk found among patients with vascular disease but not in general populations (for major CVD, I2 = 82.6 [P = .02]; for death, I2 = 90.8 [P = .001]).

    Conclusions and Relevance: Findings of this pooled analysis of 4 cohort studies indicated that a minimal fish intake of 175 g (approximately 2 servings) weekly is associated with lower risk of major CVD and mortality among patients with prior CVD but not in general populations. The consumption of fish (especially oily fish) should be evaluated in randomized trials of clinical outcomes among people with vascular disease.

  19. Attaei MW, Khatib R, McKee M, Lear S, Dagenais G, Igumbor EU, et al.
    Lancet Public Health, 2017 09;2(9):e411-e419.
    PMID: 29253412 DOI: 10.1016/S2468-2667(17)30141-X
    BACKGROUND: Hypertension is considered the most important risk factor for cardiovascular diseases, but its control is poor worldwide. We aimed to assess the availability and affordability of blood pressure-lowering medicines, and the association with use of these medicines and blood pressure control in countries at varying levels of economic development.

    METHODS: We analysed the availability, costs, and affordability of blood pressure-lowering medicines with data recorded from 626 communities in 20 countries participating in the Prospective Urban Rural Epidemiological (PURE) study. Medicines were considered available if they were present in the local pharmacy when surveyed, and affordable if their combined cost was less than 20% of the households' capacity to pay. We related information about availability and affordability to use of these medicines and blood pressure control with multilevel mixed-effects logistic regression models, and compared results for high-income, upper-middle-income, lower-middle-income, and low-income countries. Data for India are presented separately because it has a large generic pharmaceutical industry and a higher availability of medicines than other countries at the same economic level.

    FINDINGS: The availability of two or more classes of blood pressure-lowering drugs was lower in low-income and middle-income countries (except for India) than in high-income countries. The proportion of communities with four drug classes available was 94% in high-income countries (108 of 115 communities), 76% in India (68 of 90), 71% in upper-middle-income countries (90 of 126), 47% in lower-middle-income countries (107 of 227), and 13% in low-income countries (nine of 68). The proportion of households unable to afford two blood pressure-lowering medicines was 31% in low-income countries (1069 of 3479 households), 9% in middle-income countries (5602 of 65 471), and less than 1% in high-income countries (44 of 10 880). Participants with known hypertension in communities that had all four drug classes available were more likely to use at least one blood pressure-lowering medicine (adjusted odds ratio [OR] 2·23, 95% CI 1·59-3·12); p<0·0001), combination therapy (1·53, 1·13-2·07; p=0·054), and have their blood pressure controlled (2·06, 1·69-2·50; p<0·0001) than were those in communities where blood pressure-lowering medicines were not available. Participants with known hypertension from households able to afford four blood pressure-lowering drug classes were more likely to use at least one blood pressure-lowering medicine (adjusted OR 1·42, 95% CI 1·25-1·62; p<0·0001), combination therapy (1·26, 1·08-1·47; p=0·0038), and have their blood pressure controlled (1·13, 1·00-1·28; p=0·0562) than were those unable to afford the medicines.

    INTERPRETATION: A large proportion of communities in low-income and middle-income countries do not have access to more than one blood pressure-lowering medicine and, when available, they are often not affordable. These factors are associated with poor blood pressure control. Ensuring access to affordable blood pressure-lowering medicines is essential for control of hypertension in low-income and middle-income countries.

    FUNDING: Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Canadian Institutes of Health Research Strategy for Patient Oriented Research through the Ontario SPOR Support Unit, the Ontario Ministry of Health and Long-Term Care, pharmaceutical companies (with major contributions from AstraZeneca [Canada], Sanofi Aventis [France and Canada], Boehringer Ingelheim [Germany amd Canada], Servier, and GlaxoSmithKline), Novartis and King Pharma, and national or local organisations in participating countries.

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